Role Overview: The RN Care Coordinator Sr. is responsible for assessing patients' transitional care needs, coordinating care across the continuum, and facilitating discharge planning for complex cases during hospitalization. They collaborate with physicians, care teams, and patients to ensure timely care progression, identify and resolve barriers to discharge, and develop individualized discharge plans. The role includes performing assessments, managing care progression, documenting interactions, mentoring new staff, and supporting professional development.

Responsibilities:

• Assess psychosocial and resource needs and partner with the care team to establish care and discharge plans.
• Facilitate communication regarding care progression, identify delays, and work to resolve barriers for efficient discharge.
• Manage all aspects of discharge planning, including post-acute referrals and ensuring consensus with patients, families, and providers.
• Accurately document assessments, interventions, and care plans to ensure quality and compliance.
• Mentor and precept new hires and interns, supporting team development.
• Engage in ongoing professional development and contribute to departmental goals.
  
  

Qualifications: Requires an associate or diploma in nursing (bachelor's preferred), minimum of 3 years' hospital nursing experience, and 2 years' hospital case management experience. Valid RN license with BLS certification (including instructor or multi-state compact where applicable).